Diagnosis of Neonatal and Infantile Cholestasis

- Implementation Tools and Considerations

To improve healthcare provision, quality, safety, and patient outcome, evidence-based recommendations must not only be developed, but also disseminated and implemented at national and local levels and integrated into clinical practice.

Dissemination involves educating related healthcare providers to improve their awareness, knowledge and understanding of the guideline’s recommendations. It is one part of implementation, which involved translation of evidence-based guidelines into real life practice with improvement of health outcomes for the patients.

Implementation requires an evidence-based strategy involving professional groups and stakeholders and should consider the local cultural and socioeconomic conditions. Cost-effectiveness of implementation programs should be assessed.

Specific steps need to be followed before clinical practice recommendations can be integrated into local clinical practice, particularly in low resource settings.

Steps of implementing the diagnosis, and emergency treatment of neonatal and infantile cholestasis into the Egyptian health system:

1.     Develop a multidisciplinary working group.

2.     Assess the status of nutritional care delivery, care gaps and current needs.

3.     Select the material to be implemented, agree on the main goals, identify the key recommendations for diagnosis, treatment and prevention and adapt them to the local context or environment.

4.     Identify barriers to, and facilitators of implementation.

5.     Select an implementation framework and its component strategies.

6.     Develop a step-by-step implementation plan:

·       Select the target populations and evaluate the outcome.

·       Identify the local resources to support the implementation.

·       Set timelines.

·       Distribute the tasks to the members.

·       Evaluate the outcomes.

7.     Continuously review the progress and results to determine if the strategy requires modification.

Guideline implementation strategies will focus on the following: -

1.     For Practitioners

·       Educational meetings: conferences, lectures, workshops, grand rounds, seminars, and symposia.

·       Educational materials: printed or electronic information (software).

·       Web-based education: computer-based educational activities.

·       A trained person meets with providers in their practice setting to provide information with the intention of changing the provider’s practice. The information may include feedback on the performance of the provider(s).

·       Reminders: the provision of information verbally, on papers or on a computer screen to prompt a health professional to recall information or to perform or avoid a particular action related to patient care.

·       Optimize professional-patient interactions, through mass media campaigns, reminders, and education materials.

·       Practice tools: tools designed to facilitate behavioral/practice changes, e.g., flow charts.

2.     For Patients and care givers

·       Patient education materials (Arabic booklet): Printed/electronic information aimed at the patient/consumer, family, caregivers, etc.

·       Reminders: the provision of information verbally, on papers or electronically to remind a patient/consumer to perform a particular health-related behaviors.

·       Mass media campaigns.

3.     For Nurses

·       Educational meetings: lectures, workshops or traineeships, seminars, and symposia.

·       Educational materials: printed.

·       A trained person meets with nurses in their practice setting to provide information with the intention of changing the provider’s practice.

·       Reminders: the provision of information verbally, on paper or on a computer screen to prompt them to recall information or to perform or avoid a particular action related to patient care.

·       Practice tools: tools designed to facilitate behavioral/practice changes.

4.     For Stakeholders

Plans have been made to contact with all the health sectors in Egypt including all sectors of the Ministry of Health and Population, National Nutrition Institute, University Hospitals, Ministry of Interior, Ministry of Defense, Non-Governmental Organizations, Private sector, and all Health Care Facilities.

·       Information and communication technology: Electronic decision support, order sets, care maps, electronic health records, office-based personal digital assistants, etc.

·       Any summary of clinical provision of health care over a specified period may include recommendations for clinical action. The information is obtained from medical records, databases, or observations by patients. Summary may be targeted at the individual practitioner or the organization.

·       Administrative policies and procedures.

·       Formularies: Drug safety programs, electronic medication administration records.

5.     Other activities to assist the implementation of the adapted guideline’s recommendations include:

·       International initiative: Dissemination of the presented adapted CPG internationally via sending the final adapted CPG to the Guidelines International Network (GIN) Adaptation Working Group and contacting the CPG developers.

· Gantt chart has been designed to manage the dissemination and implementation stages for the adapted CPG over an accurate time frame (Appendix).

 

Guideline Implementation Tools

      I.  Stool card

Figure 1: The stool color card (SCC), English version, developed by the Perinatal Services BC (British Columbia; in Vancouver, Canada (12).

 

    II.          Cholestasis Flow Chart

 

Figure 2: Neonatal and infantile cholestasis flow chart

# Referral to pediatric hepatologist is required. CBD: common bile duct, GB: gall bladder, GGT: Gamma-glutamyl transferase, PFIC: Progressive familial intrahepatic cholestasis, PIBD: Paucity of Interlobular Bile Ducts, PT: Prothrombin time, UTI: urinary tract infection. Adopted from: Manual of some Pediatric Liver Diseases (13).